Desigualdade no acesso à saúde: sua influência na apresentação clínica das neoplasias benignas e malignas da tireoide em pacientes submetidos à tireoidectomia total

Abstract

Introduction: The social inequalities present in our society cause an evident inequality in health access. Thus, the health and illness process should consider the cultural context in which people are inserted, as well as the several social risk factors that influence this process, such as lifestyle and behavior. In this perspective we can observe such influence in several diseases, including thyroid diseases. In cases of goiter, benign thyroid disease that has primary causes iodine deficiency, most of the regions that present a greater iodine deficiency are poor regions that have difficulties of access to care. Malignant thyroid disease may also present clinic differences related to socioeconomic status, such as worse survival, tumors treatment in advanced stages, and greater presence of malignant disease in individuals with low socioeconomic status. Objective: To verify the influence of the inequalities in the health access in the clinical and histopathological presentation of the benign and malignant thyroid diseases at the time of treatment in patients undergoing total thyroidectomy in Guarapuava city. Methodology: This was a cross-sectional observational study. We examined the records of patients undergoing total thyroidectomy at a head and neck surgery service from 2003 to 2017. Demographic variables included age, sex, marital status, and health insurance type. The clinical variables included whole thyroid volume estimated by ultrasonography, thyroid disease type, pathological diagnosis, post- surgical specimens volume and weight, TNM and clinical staging in cases of malignant disease. The sample was divided into two groups, based on health insurance type, patients attended by SUS and patients who had health insurance or private care. Data was considered non-parametric, it were presented in absolute and relative frequency distribution, or mean±SD or median (CI). To analyze the data we use the tests of Shapiro-Wilk, Kolmogorov-Smirnov, Chi-square, Mann- Whitney and Kruskal-Wallis. The level of significance was p<0.05. Results: 315 patients were identified, 104 (33.02%) belonged to SUS and 211 (66.98%) private care/health insurance. Between the two groups, the whole gland volume (p<0.001) and the surgical specimen weight (p<0.001) were significantly higher in SUS patients. In malignant diseases, being a SUS patient had an association with a greater presence of metastatic deposit (p=0.030). The thyroid volume estimated by ultrasonography was lower in patients younger than 45 years, in women and in malignant diseases (p<0.001). Patients younger than 45 years had a smaller surgical specimen volume than those aged 45 years or older (p<0.001). While, the surgical specimen weight was lower in patients younger than 45 years, in patients with private health insurance (p<0.001), and in malignant diseases (p<0.049). Conclusion: Inequalities in health access may influence the clinical presentation of benign and malignant thyroid diseases at the time of treatment, mainly in relation to the whole thyroid volume, thyroid weight and presence of metastatic deposit. The variables age, sex, and pathological diagnosis influence thyroid volume and weight.